Q&A: HIV, sexual activity need to be part of conversations with older patients, experts say

A case report of an 83-year-old man in Spain who was newly diagnosed with HIV highlights the importance of screening older adults, experts said.

Enrique Garcia Carus, MD, a physician at the Central University Hospital of Asturias in Spain, presented the case report during the virtual European Congress of Clinical Microbiology & Infectious Diseases (ECCMID). The patient experienced unexplained weight loss and fever for about 1 month before tests showed he was HIV positive. He had a CD4 cell count of 182 and a high viral load of 180,564 copies/ml.

How the patient contracted HIV remains a mystery, according to a press release distributed by ECCMID. He was placed on triple antiretroviral therapy and today, 2 years after his diagnosis, “is well,” the release said.

“This case serves as a reminder that the elderly are not immune to HIV infection,” Garcia Carus said in the press release. “Health care providers need to be aware that being old does not automatically equate to being at low risk, and they should be encouraged to screen patients of all ages for HIV.”

The CDC estimates that 51% of people in the U.S. and dependent areas who had an HIV diagnosis in 2018 were aged 50 years and older. Despite their risk for infection, the authors of a previous review on HIV risk wrote that older adults are less likely than younger adults to discuss sexual risk behaviors with their physicians and to be tested for HIV.

“Thus, it is important to educate clinicians about sexual risk behaviors in the older age groups,” the authors wrote.

To that end, Healio Primary Care interviewed Paul A. Volberding, MD, the Chief Medical Editor of Infectious Disease News and professor of medicine emeritus at the University of California, San Francisco. Volberding became involved on the frontline of what became known as the AIDS epidemic 2 weeks after the disease was first discussed in a 1981 edition of MMWR. He discussed key findings from the case report in Spain and what clinicians need to know about HIV in older patients.

Healio Primary Care: What should physicians take away from this case report?

Volberding: This is an interesting case that should serve as a reminder to all that HIV infection is still here, people are still acquiring it and that sometimes we will not have a clear sense of how they acquired it.

This case reminds me of one that we had here in San Francisco in the early days of the epidemic involving an elderly nun. It is possible health care professionals were embarrassed to ask and discuss the risks for HIV with her. As it turned out, she had a blood transfusion earlier in her life and by the time she was diagnosed with HIV, she was in a very advanced stage of the disease.

Healio Primary Care: What are some misconceptions among health care professionals about older patients and their risk for HIV?

Volberding: One of the most important things health care professionals need to realize is that people can, and in many cases do, continue to have sex as they get older, and they do not necessarily become sexually inactive.

Another important consideration is that patients tend to have increasing numbers of chronic conditions as they grow older. They are often prescribed many different medicines that can have side effects that are worse in older people compared with younger populations. This includes HIV drugs.

Both these things should serve as a reminder that we really have to get to know our patients, particularly the older ones.

Healio Primary Care: Why are some health care professionals reluctant to offer HIV testing to older people?

Volberding: Their hesitancy is likely due to the stigma that many people still attach to sexual activity, and the fear of offending somebody by asking him or her a question about sexual activity, especially an older person.

Healio Primary Care: What are some of the signs of late-stage infection?

Volberding: We would see weight loss, debilitation and opportunistic infections common in persons with very low CD4 cell counts.

References

CDC.gov. HIV and older Americans. https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Accessed Aug. 4, 2021.

CDC.gov. Screening for HIV. https://www.cdc.gov/hiv/clinicians/screening/index.html. Accessed Aug. 4, 2021.

European Congress of Clinical Microbiology & Infectious Diseases. Newly diagnosed HIV infection in an 83-year-old man -- research highlights older populations still at risk. https://www.eurekalert.org/news-releases/793141. Accessed Aug. 3, 2021.

HIV.gov. HIV and AIDS timeline. https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline. Accessed Aug. 3, 2021.

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